Much about endometriosis is controversial. However, the results of some large clinical trials have helped answer many of the questions that confront patients and clinicians. Endometriosis is a female medical condition where endometrial tissue is found growing in areas outside of the uterus (usually in the pelvis). For some women endometriosis can cause pelvic pain, especially during menstruation and can cause severe discomfort with sexual intercourse. The presence of dysmenorrhea (abnormal menstrual pain) may lead a physician to suspect endometriosis especially if the pain is worsening over the course of several months. During a pelvic exam endometriosis may be suspected by palpating tender nodules behind the uterus or by visualizing a persistent ovarian cyst on ultrasound that has certain echogenic characteristics (an “endometrioma”). Many times endometriosis can be found even in the absence of symptoms or signs. The diagnosis can only be confirmed or excluded by undergoing a laparoscopy. Endometriosis is staged based on the depth of the lesions and the extent of the involvement in the pelvis. Stages 1 and 2 are termed “minimal” and “mild” endometriosis, while stages 3 and 4 are “moderate” and “severe” disease. The presence of an endometrioma in an ovary usually translates to at least stage 3.

The prevalence of endometriosis has been calculated to be 3-10% in the general population of reproductive age women; however, it is found in 40% of infertile patients. Endometriosis often runs in families.

Most experts agree that endometriosis impairs fertility. One mechanism for this effect is ascribed to an inflammatory response incited by the endometriosis lesion. White blood cells, the warriors in the body’s defense system, try to eradicate the abnormally located endometrial tissue and release substances into the pelvic cavity which have been shown to be toxic to sperm, eggs, and embryos. In addition, as the body tries to heal the inflamed areas it may inadvertently scar the fallopian tubes and/or ovaries causing them to adhere to other pelvic structures, and thereby distort the normal anatomy. Then normal anatomical relationship of the ovary and fallopian tube are crucial for natural conception since the egg must reach the fallopian tube where fertilization can take place.

There are a number of treatment options for the diminished fertility that is attributable to endometriosis. Probably the easiest treatment from the patient’s perspective is to have the endometriosis lesions surgically eradicated during the initial diagnostic laparoscopic procedure. Laparoscopy is an out-patient procedure commonly referred to as “band-aid” surgery owing to the fact that the necessary incisions are so small as to be sufficiently covered by standard band-aids. Methods to treat these lesions include electrocautery, laser vaporization, and mechanical removal. In cases of moderate or severe endometriosis it has been well-established that surgical removal of both endometriosis lesions and adhesive scar tissue improves fertility by restoring the correct anatomical relationship of the fallopian tubes and the ovary. The additional use of medications such as Lupron, a GnRH-agonist, to suppress any residual endometriosis has been advocated by some. However, numerous studies have failed to show that these medications improve fertility rates beyond that of surgery alone. This may be, in part, due to the fact that patients must avoid becoming pregnant while on these medications for fear of possibly inducing birth defects. Yet the optimal time to achieve pregnancy may be immediately following the surgery (when the fallopian tubes have just been flushed and before any scar tissue has had a chance to re-form). Post-operative medication is recommended, however, when pelvic pain is an overwhelming component of the disease, since medication can improve the chance for pain relief.

The ablation of minimal or mild endometriosis for the treatment of infertility in the absence of pelvic pain or other symptoms has been controversial. In 1997 the results of a large well-controlled clinical trial carried out by the Canadian Collaborative Group on Endometriosis were reported in the New England Journal of Medicine. The study compared the fecundity rate (pregnancy rate per month) of patients undergoing laparoscopy that were randomly assigned to have their endometriosis lesions (minimal or mild disease) either ablated or left untreated. The authors demonstrated a clear benefit in the group randomized to ablation of the lesions resulting in a doubling of the fecundity rate over the ensuing 8 months when compared to the group whose lesions were not treated during their laparoscopy.

Another common method for treatment of infertility in patients with endometriosis who have at least one patent fallopian tube is injectable gonadotropin superovulation with or without intrauterine insemination. Up to 3 cycles is routinely offered to such patients. This practice is supported by a randomized study of patients with mild to moderate disease which revealed that superovulation yielded a 15% fecundity rate (4 times higher than those patients who simply tried on their own for 6 months).

For patients who fail to conceive within one year after surgical ablation of moderate to severe endometriosis, the most successful therapy is in vitro fertilization (IVF). A study that compared IVF to re-operation for endometriosis found that only 24% of the re-operated patients achieved a pregnancy by 9 months post-operatively while 70% of the IVF patients were pregnant by their second cycle. Some doctors reported in the 1990’s that patients with endometriosis had lower success with IVF than did patients with other diagnoses (such as tubal blockage, male factor, or unexplained infertility). Various mechanisms were cited including diminished fertilization, poor embryo quality, and impaired endometrial receptivity. However, the national IVF data bank for the past decade has not shown any diminished success rates in the patients with endometriosis compared to those without that diagnosis.

In summary, the prognosis for achieving a successful pregnancy in patients with endometriosis-related infertility is reasonably high, especially if the lesions are ablated and if empiric gonadotropin superovulation is employed. Post-operative medication to inhibit hormones does not seem to enhance fertility. IVF should be encouraged in patients who fail to conceive with these less aggressive measures. Though it may be useful for treating pelvic pain, a repeat attempt at surgical correction of endometriosis is less successful than is IVF in overcoming infertility.

For more information, please call South Jersey Fertility Center at (856) 596-2233 or visit www.sjfert.com.

Peter VanDeerlin, M.D., F.A.C.O.G.

Dr. Peter Van Deerlin completed his residency at Washington University Medical Center and his Fellowship in Reproductive Endocrinology at the University of Pennsylvania Medical Center. He is Board Certified in Obstetrics/Gynecology and Reproductive Endocrinology/Infertility. Dr. Van Deerlin joined South Jersey Fertility Center in 1997 and has earned the respect and trust of his patients through a career marked by commitment to individualized patient care.

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